6 Colo. Code Regs. § 1011-1-20-4

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-20-4 - GOVERNING BODY

4.1 Responsibility: The governing body shall provide facilities, personnel, and services necessary for the welfare and safety of the patients.

4.2 Duties: The governing body shall:

(A) Adopt bylaws in accordance with applicable legal requirements;

(B) Meet regularly and maintain accurate records of such meetings;

(C) Appoint committees consistent with the needs of center;

(D) Appoint and delineate clinical privileges of practitioners based upon recommendations by the medical staff and other appropriate indicators of physician and other licensed practitioner competence. Each member of the medical staff shall be granted privileges that are commensurate with the member's qualifications, experience, and present capabilities and that are within the practitioner's scope of practice;

(E) Maintain an up-to-date roster of providers credentialed by the center that specifies the approved surgical and/or procedural privileges of each provider. The roster shall be available to the nursing staff at all times;

(F) Establish a formal means of liaison with the medical staff;

(G) Approve bylaws, rules and regulations of the medical staff;

(H) Develop written policies and procedures in cooperation with the medical staff. The procedures shall address the acceptance, care, treatment, surgical and anesthesia services, discharge, referral and follow-up of all patients and all incidental operations of the center. The policies and procedures shall be available to all staff in the center and shall be followed by them at all times in the performance of their duties. The governing board shall also define the scope of services provided within the center;

(I) Conduct, with the active participation of the medical staff, an ongoing, comprehensive self-assessment of the quality of care provided, including the medical necessity of procedures performed, the appropriateness of care, and the appropriateness of utilization. This information shall provide a basis for the revision of center policies and the granting or continuation of clinical privileges;

(J) Adopt a national standard for infection control;

(K) Ensure the center maintains an adequate number of qualified personnel;

(L) Maintain effective quality control, quality improvement and data management;

(M) Appoint an administrator qualified by education and experience as defined in the job description developed by the center; and

(N) Appoint a member of the medical staff to act as medical director for the center.

6 CCR 1011-1-20-4